Financial Agreement
We, the Dental Team of Yakov M. Royzman. D.D.S.thank you for choosing us as your dental provider. We consider it a privilege to serve your needs and we look forward to doing so. We are committed to providing you with the highest level of care and to building a successful provider-patient relationship with you and your family. We believe your understanding of our patients’ financial responsibility is vital to that provider-patient relationship and our goal is to not only inform you of the provisional aspects of that financial policy but also to keep the lines of communication open regarding them. If at any time you have any questions or concerns regarding our fees, policies, or responsibilities please feel free to contact our manager at (212)579-0552.
We believe this level of communication and cooperation will allow us to continue to provide quality service to all of our valued patients.
Please understand that payment for services is an important part of the provider-patient relationship. If you do not have insurance, proof of insurance, or participate in a plan that will not honor an assignment of insurance benefits, payment for services will be due at the time of service unless a payment arrangement has been approved in advance by our staff.
We make payment as convenient as possible by accepting (cash, money order, major credit cards, and in-statechecks). A $37.00 service fee (or whatever service fee bank applies) will be charged for all returned checks. Additionally, you may authorize us tokeep your credit card on file for your convenience knowing that we adhere to the highest level ofinformation security.
Interest
A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 30 days.
Insurance
Please remember that your insurance policy is a contract between you and your insurance carrier. We will,as a courtesy, bill your insurance and help you receive the maximum allowable benefit under your policy.We have found that patients who are involved with their claims process are more successful at receivingprompt and accurate payment services from their insurance carrier. We do expect patients to be interactiveand responsible for communicating with your insurance carrier on any open claims.
It is your responsibility to provide all necessary insurance eligibility, identification, authorization and referralinformation and to notify our office of any information changes when they occur. Even a preauthorizationof services does not guarantee payment from your insurance carrier. We also require photo identificationwhen accepting insuranceinformation. It is the patient’s responsibility to know if our office is participatingor non-participating with their insurance plan. Failure to provide all required information may necessitatepatient payment for all charges. When insurance is involved, we are contractually obligated to collect copayments,co-insurance, and deductibles, as outlined by your insurance carrier.
Please be aware that out-of-network insurance carriers often prohibit assignment of benefits and may try tolimit their financial liability with arbitrary limits, exclusions, or reductions such as reasonable and customaryor usual and prevailing reductions. Our fees are well within such ranges and although we will assist in thefiling of an appeal if these limitations are imposed, you as the guarantor are responsible for all out-ofnetworkfees. If we are not contracted with your carrier we will not negotiate reduced fees with your carrier.
Miscellaneous Forms, Additional Information and Authorizations
We will provide all necessary information to have your benefits released. However, if it becomes necessaryto submit redundant or unnecessary information for the completion of claim forms for school, sports, orextra curricular activities there will be an administrative fee, not to exceed $35.00, for the additionalinformation.
Missed Appointments
We require notice of cancellations 24 hours in advance. This allows us to offer the appointment to anotherpatient. If you fail to keep your appointments without notifying us in advance: a missed appointment feewill apply. These fees are typically $25.00 but not to exceed one-half of the cost of your scheduledappointment. Repeated missed appointments without notification may cause you to be discharged from thepractice so that we canprovide care to other patients.
Medical Records Fees
Patients are entitled under federal law to have access to their protected health information and we follow allrules, guidelines, and exceptions to ensure compliance to patient rights. However, providers also have theright to compensation for records and our fees are a reasonable cost-based fee for copies including thecopying, supplies, labor, and postage of the files, and or summaries.
Timeliness of Appointments
We try to see everyone in a timely manner but if we are taking too long, please let our receptionist know sowe can best serve your needs and reschedule you if necessary.
We realize that temporary financial problems may affect timely payment of your account. If this should occur, please contact us for assistance in the management of your account. Our goal is to provide quality care and service. Please let us know immediately if you require any assistance or clarification from anyone within our business.
I have read and understand the above financial policy. I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered. I also will be responsible for the fee charged by the collection agency for costs of collections if suchaction becomes necessary.
Signature of Insured or Authorized Representative: ______
Date: ______
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Your Rights
Get an electronic or paper copy of your medical record
• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
Request confidential communications
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by contacting us using the information on page 1.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C.20201, calling 1-877-696-6775, or visiting
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care• Share information in a disaster relief situation• Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
• Marketing purposes • Sale of your information • Most sharing of psychotherapy notes
Our Uses and Disclosures
Treat you
We can use your health information and share it with other professionals who are treating you.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:
Help with public health and safety issues
We can share health information about you for certain situations such as:
• Preventing disease• Helping with product recalls• Reporting adverse reactions to medications• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety
Do research
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
• For workers’ compensation claims• For law enforcement purposes or with a law enforcement official• With health oversight agencies for activities authorized by law• For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Our Responsibilities
• We are required by law to maintain the privacy and security of your protected health information.• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.• We must follow the duties and privacy practices described in this notice and give you a copy of it.• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see:
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office.
I have read and understand the above Notice of Privacy Practices.
Signed______Date______
(Patient or Legal Guardian)